Cost-effectiveness of intensive v. standard case management for severe psychotic illness

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Abstract
Background: Intensive case management is commonly advocated for the care of the severely mentally ill, but evidence of its cost-effectiveness is lacking.Aims: To investigate the cost-effectiveness of intensive compared with standard case management for patients with severe psychosis.Method: 708 patients with psychosis and a history of repeated hospital admissions were randomly allocated to standard (case-loads 30–35) or intensive (case-loads 10–15) case management. Clinical and resource use data were assessed over two years.Results: No statistically significant difference was found between intensive and standard case management in the total two-year costs of care per patient (means £24 550 and £22 700, respectively, difference £1850, 95% Cl – £1600 to £5300). There was no evidence of differential effects in African–Caribbean patients or in the most disabled. Psychiatric in-patient hospital stay accounted for 47% of the total costs, but neither such hospitalisation nor other clinical outcomes differed between the randomised groups.Conclusion: Reduced case-loads have no clear beneficial effect on costs, clinical outcome or cost-effectiveness. The policy of advocating intensive case management for patients with severe psychosis is not supported by these results.